Hospital Association Teams with State to Standardize Patient Alert Bands

October 22, 2007 – Hospitals routinely use color-coded wristbands to alert caregivers to patient conditions, but they can have unintended consequences if caregivers are not clear about the meanings of the colors, so the New Jersey Hospital Association and the New Jersey Department of Health and Senior Services launched a patient safety effort last week to standardize color-coded wristbands.
“With the increased popularity of special-cause wristbands, along with the fact that every care setting has its own policy, there is the potential for confusion,” said NJHA President and CEO Gary Carter. “Fortunately, no such instances have been reported in New Jersey, but some scary near-misses have been reported elsewhere in the country. We wanted to act now, before an unfortunate event occurs.”
In one such instance in another state, Carter said a patient nearly died when a caregiver was confused about the meaning behind a yellow patient wristband. The patient had gone into cardiac arrest, but a caregiver mistook the patient’s yellow wristband as signifying a “do not resuscitate” order. In actuality, the yellow was intended to alert staff that the patient should not have blood work or an IV placed in that particular arm. The caregiver, who worked in two different facilities, apparently had confused the meanings between the two different facilities, delaying a rapid response for the patient.
New Jersey’s effort involved hospitals, long-term care facilities, ambulatory care settings, home health providers and emergency responders, as well as the professional organizations that represent these facilities and the professions involved.
“Supporting healthcare facilities in developing patient safety programs is a high priority for this administration,” said State Health Commissioner Dr. Fred Jacob. “The department’s patient safety initiative collaborates with providers using national models for best practices and encourages the development of activities that improve performance.”
The need for this program was underscored in April when a survey of 75 New Jersey healthcare facilities identified a variety of colors and means of communicating patient risk factors. In acute care settings alone, 10 different colors alerted caregivers of 19 different risk factors.
“If a patient came to the emergency room from a neighboring long term care facility wearing a red wristband, there was no guarantee that the two institutions were identifying the same risk,” said Mary Ditri, NJHA’s director of professional practice, who led the project.
The initiative is being unveiled to facilities statewide as voluntary guidelines. NJHA has developed an implementation toolkit, posters and brochures to educate caregivers and patients about the initiative. The following colors with their corresponding risk factors were chosen:
- Red - Allergy
- Yellow - Fall Risk
- Green - Latex Allergy
- Purple - Do Not Resuscitate
- Pink - Restricted Limb